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Social Action Theory for a Public Health Psychology

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Social Action Theory for a Public Health Psychology Social Action Theory for a Public Health Psychology Craig K. Ewart Department of Health Policy and Management, Johns Hopkins University Many illnesses can be prevented or limited by altering advanced disease control and enhanced quality of life in personal behavior, and public health planners have turned ways that would not have been possible in a clinical model. to psychology for guidance in fostering self-protective ac- Early attempts to determine who became sick, and where tivity. A social theory of personal action provides an in- and when, for example, led to significant reductions in tegrative framework for applying psychology to public the prevalence of infectious diseases long before the bio- health, disclosing gaps in our current understanding of logical mechanisms of these illnesses could be explained self-regulation, and generating guidelines for improving or modified. A population perspective can reveal a pre- health promotion at the population level. A social action viously unrecognized environmental hazard or a wide- view emphasizes social interdependence and interaction spread health-endangering personal behavior that when in personal control of health-endangering behavior and altered even slightly may reduce the burden of human proposes mechanisms by which environmental structures suffering and lower the cost of medical care. This per- influence cognitive action schemas, self-goals, and prob- spective has led to public health's long-standing emphasis lem-solving activities critical to sustained behavioral on disease prevention and on viewing the entire com- change. Social action theory clarifies relationships between munity-rather than the individual--as the patient. social and personal empowerment and helps explain stages Public health's interest in individuals and in pro- of self-change. cesses of personal change has increased, however, with mounting evidence linking major health threats to mod- ifiable human behaviors (Sexton, 1979; Surgeon General, Every year millions of people suffer and die of illnesses 1979). Public health is an empirically driven, problem- that could be curbed or eliminated by altering patterns focused enterprise that looks to various disciplines for of personal behavior. Modifiable habits and customs con- needed theoretical and technical resources. Yet those who tribute to malnutrition, communicable diseases, and would apply behavior change methods of psychology to chronic illnesses, and thereby augment a staggering toll populations quickly discover that these efforts can go awry of needless deaths (Elder, 1987). To lower this toll, public (Jeffery, 1989). Interventions directed at individuals can health planners have turned to psychology--and es- prove more expensive than the "passive" environmental pecially to its models of self-regulation--for guidance in prevention strategies long championed in the public health fostering self-protective action among those at risk. Yet movement and may unintentionally "blame the victim" psychological theories and models often seem of limited by implying that people are personally responsible for value when applied to public health problems, and some illnesses caused by unhealthy physical and social envi- public health theorists have questioned their usefulness ronments (Runyan, DeVellis, DeVellis, & Hochbaum, in the global struggle against disease (Jeffery, 1989; Lev- 1982; Williams, 1982). Moreover, the dominant diag- enthal, Cleary, Safer, & Gutman, 1980). I argue that psy- nostic model in public health envisions an interaction chology does have a role to play, but that this role is con- between a host (e.g., disease victim), an agent (e.g., health- strained by inattention to pathways by which social en- damaging organism or substance), and the environment. vironmental phenomena affect cognitive and biologic Psychological theories focus on the host. They explain regulatory processes. I propose a theory of personal action important phenomena of individual learning, memory, designed to foster social-contextual analysis of personal choice, and performance. Yet public health planners often change. This analysis poses important questions for self- have difficultyapplying these theories to the practical tasks regulation theory and discloses new opportunities for of designing protective legislation, educating the public, psychology to contribute to human health and well-being. and fashioning healthier occupational work or living en- vironments (Faden, 1987). These tasks require a multi- Public Health and Psychology leveled conception that views host processes as subeom- The term public health embraces a diverse array of prob- ponents of larger social and environmental systems. lem-solving and health-protective activities inspired by the practice of viewing illnesses in a social context. By Preparation of this manuscript was supported in part by Grant R01- relating the afflictions of individuals to the groups to HL36298 from the National Heart, Lung,and Blood Institute. which they belong or to the environments in which they I thank LawrenceKincaid and DonaldSteinwachs for their helpful comments on an earlier draft. work and live, the public health outlook differs from that Correspondenceconcerning this article shouldbe addressedto Craig of clinical medicine, which treats diseases as attributes K. Ewart, Health Services R & D Center, Johns Hopkins School of of isolated sufferers. This social-contextual approach has Hygieneand PublicHealth, 624 North Broadway,Baltimore, MD 21205. September 1991 • American Psychologist 931 Copyright 1991 by the American Psychological Association, Inc. 0003-066X/91/$2.00 Vol. 46, No. 9, 931-946 Self-Regulation system, so behavioral interventions strengthen self-reg- ulatory systems that foster capacity for self-protective ac- By the mid 1970s, interventions based on social learning tion (Ewart, in press). These self-regulatory systems can principles were seen to offer the most effective, widely be viewed as interconnected cybernetic control loops op- applicable method for changing behaviors that contrib- erating at physiologic, cognitive, and social levels (See- uted to leading causes of preventable deaths (e.g., Ban- man, 1989).1 dura, 1969; Kanfer, 1977). With its emphasis on cognitive Applying the framework to an analysis of population mediation of learning through modeling and vicarious interventions discloses gaps in our current understanding reinforcement, social learning theory stimulated the cre- of self-regnlation and suggests how public health strategies ation of interventions to prevent heart disease and cancer targeting individuals might be improved. To highlight by altering habits related to eating (Stunkard & Penick, these problems and possibilities, I apply here the tripartite 1979), smoking (Leventhal & Cleary, 1980), exercise model to self-regulation of coronary and cancer risk be- (Martin et al., 1984), and substance use (Marlatt & Gor- haviors involving diet, physical activity, and tobacco or don, 1985). These developments provided both a theo- alcohol use, as these have generated the largest health retical and a practical foundation for communitywide in- literature on self-regnlation. The model's three dimen- terventions such as the Stanford Five-Community Study sions (Figure 1), respectively, emphasize the role of social (Farquhar et al., 1985) and the Minnesota Heart Health context in maintaining health routines or habits (action Program (Blackburn et al., 1984). During the 1980s, so- state dimension), provide a causal framework linking self- cial learning theorists expanded their purview to include change processes to interpersonal environments (process a variety of cognitive phenomena subsumed under the dimension), and specify macrosocial and environmental rubric "social-cognitive theory" (Bandura, 1986), and influences that empower or constrain personal change control and systems concepts were incorporated into (contextual dimension). 2 models of self-regulation (Bandura, 1989; Carver & Scheier, 1981; Hyland, 1988; Schwartz, 1983). Goals, Self-Regulation as an Action State feedback functions, and attendant systems constructs helped delineate processes by which people overcame de- The first challenge in public health intervention is to de- structive behavior patterns and strengthened self-protec- fine appropriate self-regulatory goals. In most cases, pre- tive capabilities (Weinstein, 1988). vention entails creating self-protective habits in the form of highly routinized and "automatic" action sequences Social Action Theory that lower personal risk. Health habits are easily repre- Although these developments expand a theory of personal sented by a simple action-outcome feedback loop, in change, they do not meet public health's need for a con- which self-regulation is a condition of self-sustaining, dy- textual theory of individual action that incorporates namic equillibrium between self-protective activities and modifiable social and personal mechanisms of self-control their experienced biologic, emotional, and social conse- within an environmental model. Those who would en- quences. Habitual eating, exercise, smoking, or drinking courage self-regulation on a wide scale require a frame- activities tend to follow predictable scripts, in which suc- work for solving the problems that have hindered attempts cessive events in an action sequence reinforce preceding to implement self-change as a public health strategy acts and guide subsequent action components (Kazdin, (Leventhal, Zimmerman, & Gutman,
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